California Newborn Screening Program

Instructions for Completing and Submitting the Online results request Form

IMPORTANT: If filling out form online in Adobe Acrobat Reader press the toggle button "Highlight Fields" in the upper right of the screen to show fields to be completed and fields that are required. If you do not know an answer for a required field indicate with an NA.

SUBMIT AND PRINT BUTTONS

SUBMIT BY EMAIL - This allows student to immediately submit data so that processing can begin. It reduces data entry errors and significantly improves turnaround time. When submit button is pushed instructions will pop up describing how to accommodate the email system that the submitter is using. Please follow these instructions and know that when we receive your electronic data we will send a confirmation (usually within a day or two). If data are not received electronically, processing will begin when a signed hardcopy of the form is received. IMPORTANT - Results will NOT be provided until a form SIGNED in ink has been received!

PRINT FORM - Press this button to print form on your local printer. Again, results will not be provided until we have received a printed and signed in ink copy of this form.

STUDENT'S INFORMATION

Most fields should be self-explanatory. But because of issues in the past, here are some specifics that may help. For the field Last Name - Give STUDENT's last name at time of birth (include hyphenated names if need be). For the field Date of Birth - Give the STUDENT's date of birth. For the field Hospital of Birth - Indicate the name of the hospital the STUDENT was born in and the name of the city the hospital is located in. NOTE: We only provide data on California births.

BIRTH MOTHER'S INFORMATION

Birth mother’s first name, last name and maiden name at the time of the STUDENT's birth are required. Please provide every possible name that may have used at that time. Include hyphenated names if appropriate. Birth mother’s date of birth is also required. If mother’s year of birth is not available, please give month and day with the year as 9999. We have found that the birth mother’s address and city at the time of the STUDENT’s birth are very helpful for matching, but these fields are not required.

RELEASE RECORDS TO

For the field Name of School - Choose student’s school from the dropdown menu on the fillable form. If student’s school is not listed in the dropdown menu, provide the name of the school and be certain to provide (right below it) an email address where results should be sent for that school. This email address is vitally important since it is the best way for us to contact a school that we do not have in our dropdown menu.

For the field Attention - Please fill out the name of the person or department where results should be sent. If no name provided, results will be sent to the contact person on file for the school chosen from the dropdown menu.

For the field This Authorization for the Release of Your Records Will Expire On: - This is an expiration date on the release of your records. In other words, your results will only be available to be shared by the State program up until this date of expiration. We have automatically set the field to provide a date that expires one year from the date you complete the form. You may change this date. If changing online, just type the new date in the field. If changing after form printed, cross out the default date and provide your own date of expiration.

SIGNATURE

STUDENT MUST SIGN IF 18 OR OLDER. PARENT OR LEGAL GUARDIAN IS TO SIGN ONLY IF STUDENT UNDER AGE 18! If form is signed by parent/guardian and student is 18 or older or if student is under 18 and form not signed by parent/guardian, results cannot be processed. When completing online a warning will pop up indicating who should sign. The student’s date of birth and the date the form is completed are used to determine student age.

A signature (in ink) is required on a hardcopy of this form. No computer generated signatures are accepted at this time. Some schools have requested that students give their signed hardcopies to their school athletic departments. Other schools have requested that students send signed hardcopies directly to the State. They can be mailed to: California Department of Public HealthGenetic Disease Screening ProgramNewborn Screening Branch850 Marina Bay Parkway, F175Richmond, CA 94804or faxed to: 510/412-1559or scanned in and emailed to: NCAANBSResults@cdph.ca.gov.